Please complete the below form. Thank you for helping us with our research. If you
are under 18 please ask your parent or guardian to
email us their consent to take this test.
Information you provide is confidential and is used
for H.E.A.R.'s research purpose only. Please answer
these questions to the best of your ability. Thanks!

1. How did you first notice or suspect
that you were losing your hearing?

2. How long after noticing your
hearing loss did you visit a doctor or hearing
care professional?

3. How did you go about seeking
improvement for your hearing loss? (e.g.: friends,
PCP, research)

4. How long after being tested and
confirmed that you had hearing loss did you decide
to purchase hearing aids?

5. What were your top three greatest
concerns in regards to wearing a hearing aid?

6. How did you decide on what type
and brand of hearing aid(s) to purchase?

7. Did anyone in particular influence
your purchase decision?

Yes
No

8. What is the price range that
you expected to pay for one hearing aid?